四例中国青少年的成人起病型糖尿病2型家系的临床与分子遗传学研究

目的探讨中国青少年的成人起病型糖尿病2型（MODY2）患者的临床特点和分子遗传学特征。方法对2013年2月至8月北京协和医院诊断的4例MODY2家系患者的临床特点及实验室检查资料进行系统性分析并抽提相关家系成员的基因组DNA,聚合酶链式反应（PCR）扩增后进行葡萄糖激酶（GCK）基因直接测序。结果在4例家系中共诊断10例GCK基因突变引起的糖尿病和糖调节受损患者。在8例有临床资料的患者中,高血糖的诊断年龄为5．3～44．0岁,查体是主要发现形式,所有患者血甘油三酯水平均正常或低于正常下限。4个家系的GCK基因检测发现2个新突变c．749G〉A（R250H）和C．781G〉C（G261R）和2个已报突变e．127C〉T（R43C）和c．571C〉T（R191W）。结论中国MODY2患者临床表现多样,GCK基因C．749G〉A突变可能是MODY2的致病原因。     

葡萄糖激酶基因突变导致的青少年起病的成人型糖尿病家系三年随访观察及文献复习

目的 探索葡萄糖激酶(GCK)基因突变导致的青少年起病的成人型糖尿病(MODY)家系的临床特点。方法 对北京协和医院内分泌科诊断的1例GCK基因突变导致的MODY(GCK-MODY)患者及其家系进行临床特点分析,采用全外显子测序及Sanger测序验证对先证者及相关家系成员行GCK基因的检测,对先证者及其父亲进行为期3年的随访,并对GCK-MODY治疗随访相关文献进行检索和复习。结果 先证者及其父亲均检测到GCK基因10号外显子突变c.1348G>T(p.Ala450Thr)。对先证者采用饮食及运动控制,2019年随访,空腹血糖(FPG,6.8 mmol/L)、餐后2 h血糖(2hPG,7.4 mmol/L)及糖化血红蛋白(HbA1c,6.3%)均在目标范围之内,稳态模型法评估的胰岛素抵抗指数(HOMA-IR)较基线(4.09)有所改下降(2.32),葡萄糖处置指数(DI)较基线(16.22)有所改善(20.05)。对先证者父亲治疗则从胰岛素+阿卡波糖调整为磺脲类单药治疗,空腹及餐后血糖控制尚可,HbA1c较基线下降0.5%～0.7%,HOMA-IR及胰岛β细胞功能稳定。结论 及时...     

一个葡萄糖激酶基因Gly162Asp错义突变致青少年发病的成年型糖尿病2型家系报告

目的对一个高度怀疑青少年发病的成年型糖尿病2型(MODY2),即葡萄糖激酶(GCK)基因突变所致MODY家系寻找基因突变位点,并探讨其临床特点。方法对1例意外发现血糖升高、无酮症倾向、有糖尿病家族史的10岁女孩采用芯片捕获高通量测序方法进行致病基因检测,发现其携带GCK基因突变,对其家系进行调查,收集家系成员相关临床资料并取得家系成员的外周血基因组DNA,使用Sanger测序技术对家系成员进行筛查。结果该家系的5名成员检测到GCK基因(NM_000162)第5号外显子c.485GA(p.Gly162Asp)杂合错义突变,其中有4例为糖尿病患者,1例为IGR,该突变与糖尿病和IGR共分离,在白种人群中已有报道,在中国人群中为首次发现。结论 GCK基因突变c.485GA是该MODY2家系的主要致病基因。     

两个MODY2中国家系葡萄糖激酶基因杂合突变的研究

目的 寻找两个典型的MODY2家系的责任基因. 方法 抽提两个MODY2家系成员基因组DNA,PCR扩增、直接测序候选基因葡萄糖激酶(GCK)基因5′端、3′端非翻译区及1～10号外显子,确认突变. 结果 家系1中4人携带GCK基因杂合突变c.661G>A(E221K),先证者为MODY2,另2名突变携带者表现为糖调节受损(IGR),1名突变携带者血糖正常.家系2中2人携带GCK基因杂合突变c.771G>A(W257ter),先证者为MODY2,另1名突变携带者表现为IGR.在这些患者中,饮食控制和增强运动能收到良好效果. 结论 GCK基因突变c.661G>A(E221K)和c.771G>A(W257ter)可能是两个MODY2家系的主要致病基因,其中c.771G>A(W257ter)是一个新发现的突变位点.     

5个葡萄糖激酶基因突变家系的临床特征与遗传分析

目的报道并总结5个葡萄糖激酶(GCK)基因突变导致的青少年成人起病型糖尿病2型(MODY2)家系临床表现和分子遗传学特征。方法收集先证者临床资料和生化检查。采集先证者及一级家属外周血, 采用二代测序法进行全外显子组基因检测。与数据库对比筛选可疑致病位点进行Sanger测序验证。结果 5位先证者均表现出轻度空腹高血糖, HbA1C<7.5%, 无口渴、多饮、多尿症状。5个家系中存在6个突变位点, 其中M1:c.555delT(p.Leu186Cysfs Ter19)和M3:c.263T>A(p.Met88Lys)未见文献报道。随访过程中, 5位先证者除2位妊娠女性建议根据胎儿基因型, 必要时应用胰岛素治疗外, 余均行生活方式干预。结论在符合MODY诊断标准的患者中, 对于轻度高血糖、家族史明确的儿童或妊娠期女性应进行MODY2筛查, GCK基因检测是诊断金标准, 精准诊断将有利于选择更合适的治疗方案。     

5个青少年起病的成人型糖尿病2型家系的临床及遗传学分析

目的探讨青少年起病的成人型糖尿病2型(MODY2)患者的临床及分子遗传学特征。方法收集西安市儿童医院内分泌遗传代谢科近2年诊断的5例MODY2患者及其家系成员的临床资料和实验室检查结果。对所有先证者行全外显子组基因检测, 筛选出的变异位点在各家系中行Sanger测序验证。结果 5个先证者中除先证者4有多饮多尿表现外, 其余患儿的高血糖均为意外发现。所有先证者尿常规、尿蛋白五项及血脂均无异常, HbA1C 5.96%～8.15%。不同于以往MODY2患者, 本研究发现先证者5同时存在胰岛素抵抗。基因检测证实5个家系均存在葡萄糖激酶(GCK)基因突变, 共包含4种突变类型:c.146C>T(p.T49I)、c.1237T>G(p.Y413D)、c.683C>T(p.T228M)及c.952G>T(p.G318W)。c.1237T>G(p.Y413D)及c.952G>T(p.G318W)为尚未报道的新突变。给予所有先证者生活方式干预, 血糖控制相对平稳。结论 MODY2可能合并胰岛素抵抗;该病治疗可仅给予生活方式干预, 效果良好;本研究发现的GCK基因2个...     

中国人群平均血糖与糖化血红蛋白转换关系的初步分析

目的 采用动态血糖监测（CGM）技术探讨不同糖代谢人群24 h平均血糖水平（MBG）与糖化血红蛋白（HbA1c）的关系,并初步建立不同HbA1c水平其相对应的MBG值.方法 选取2007年8月至2010年1月于上海交通大学附属第六人民医院门诊及病房进行口服葡萄糖耐量试验（OGTT）的受试者318人,其中正常糖调节组115名、糖调节受损组57例、新诊断2型糖尿病患者组146例.糖尿病、糖调节受损的诊断采用2003年美国糖尿病学会（ADA）糖尿病诊断标准.测量各组生化指标,并行OGTT,测定糖负荷后2 h血糖（2 h PG）.采用CGM系统估算MBG水平,高压液相法测定HbA1c水平,分析MBG与HbA1c间的关系.统计学采用单因素ANOVA方差分析、Kruskal-Wallis检验、χ^2检验、Spearman相关分析及线性模型进行数据统计.结果 318例研究对象中总体HbA1c水平为（6.6±1.5）%,MBG水平为（7.3±2.3）mmol/L.（2）MBG与HbA1c呈显著正相关（r=0.848,P〈0.01）,其回归方程为MBG=1.252×HbA1c-0.992（R^2= 0.718,P〈0.01）,即HbA1c每升高1%,MBG相应升高1.252 mmol/L.HbA1c=6.5%时,对应的MBG值为7.1 mmol/L.HbA1c=7.0%时,对应的MBG值为7.8 mmol/L.（3）仅包括146例新诊断2型糖尿病患者的MBG和HbA1c之间的关系与总人群的结果一致（r=0.788,P〈0.01）,线性回归方程为MBG=1.255×HbA1c-0.886（R2=0.621,P〈0.01）.当HbA1c= 6.5%时,MBG对应值为7.3 mmol/L.HbA1c=7.0%时,对应的MBG值为7.9 mmol/L.结论 初步建立了各HbA1c水平其相应的MBG值,为深入开展中国人群平均血糖与HbA1c转换关系研究提供了线索.     

中国人MODY/NIDDM家系葡萄糖激酶和肝细胞核因子1α基因缺陷的分子筛查

目的 探索包含青少年起病的成人型糖尿病(maturity-onset diabetes of the young,MODY)患者的2型糖尿病家族中可能存在的MODY基因的致病突变。方法 选择MODY基因中突变率最高的葡萄糖激酶(GCK，MODY2)和肝细胞核因子1α(HNF—1α，MODY3)基因的微卫星多态遗传标志在2个包含临床MODY患者的中国人2型糖尿病家系中进行连锁分析，对HNF—1α基因进行全基因外显子的突变筛查--DNA序列直接测定以明确具体的核苷酸突变和所编码的氨基酸的改变。结果 HNF—1α基因标志物在家系50001中MODY3的最大LOD值达到2．38(θ＝0．00)，家系50002中，MODY3最大LOD值达到3．59(θ＝0．00)；两家系均末发现与MODY2连锁的依据。DNA直接测序发现在家系50001中所有家族成员外显子7中存在一个杂合多态SeR487 Asn(AGC／AAC)，该多态在正常人中也可见到；家系50002中NIDDM／MODY个体MODY3基因外显子5编码区存在一个杂合错义突变Tyr322 Asn(TAT→AAT)。结论 GCK基因内或附近的基因变异不是本家系糖尿病的主要致病原因；家系50001中，HNF—1α基因的启动子和所有外显子内没有发现明确的致病突变，但不能否定内含子或其他调节区域的变异可能的致病倾向；由于本家系遗传标志D12S86与糖尿病的连锁LoD最大值达到2．38(9＝0．00)，所以也不能排除HNF—1α基因附近其他未知疾病基因的致病可能。家系50002中HNF—1α基因外显子5中发现的杂合错义突变Tyr(TAT／AAT)Asn有可能是一个疾病关联突变，具体致病的机理有待蛋白质功能研究证实。     

一个新的葡萄糖激酶基因-E339K突变导致的中国人青少年发病的成年型糖尿病2型家系

目的 寻找一个典型的青少年发病的成年型糖尿病2型(MODY2)家系的责任基因.方法 抽提MODY家系成员基因组DNA,PCR扩增、直接测序候选基因葡萄糖激酶(GCK)基因5'端、3'端非翻译区及1～10号外显子,确认突变.结果 在MODY2家系中确认了一个新型的GCK-E339K突变,该突变与糖尿病或糖耐量异常共分离.结论 GCK-E339K突变可能与该MODY2家系相关,是该MODY2家系的责任基因.     

青少年的成人起病型糖尿病2型和3型混合家系一例临床分析并文献复习

目的探究葡萄糖激酶基因(GCK)及肝细胞核因子1α基因(HNF-1α)同时突变致青少年的成人起病型糖尿病(MODY)的临床和遗传学特点。方法对北京协和医院2017年9月诊断的一例MODY患者及其家系的临床特征、实验室资料进行分析;对家系成员进行MODY相关致病基因检测。结果该家系的5名成员检测到GCK基因(NM_000162)c.686C>T(p.Thr229Met)杂合突变。其中3名成员同时检测到HNF-1α基因(NM_001306179)c.1531C>G(p.Gln511Glu)杂合突变。结论MODY混合家系GCK及HNF-1α基因突变导致同一家系出现不同的MODY类型。诊断时需考虑混合家系的可能性,以准确诊断。     

MODY2的认识及诊疗进展

青少年发病的成年型糖尿病2型(MODY2)由葡萄糖激酶(GCK)基因突变所致,以空腹血糖及糖化血红蛋白水平轻度升高并保持稳定状态为主要表现,多不增加糖尿病并发症及相关代谢疾病的发生风险,无需降糖治疗.但对于妊娠期患者,若胎儿未携带突变基因,妊娠相关并发症及巨大儿发生风险增加,故此类患者需积极降糖治疗.     

Clinical profiling and screening for HNF4α and GCK gene mutations in Kashmiri patients with maturity-onset diabetes of the young (MODY)

AimMaturity-onset Diabetes of Young (MODY) is a monogenic form of diabetes affecting 1–5% of young (often ≤25 years) diabetic patients exhibiting an autosomal dominant mode of inheritance. Considering the significance of genetic polymorphisms in a variety of diseases, this study aimed to determine the association between HNF4α and GCK gene polymorphisms and the risk of MODY in the Kashmir community, as well as their clinical differences.MethodThe study was conducted on clinically confirmed MODY patients (n = 50), and age and gender-matched controls (25 T1DM and 25 non-diabetic) recruited from the endocrinology department of the hospital, for evaluating the HNF4α and GCK mutation. Under standard conditions, PCR-mediated amplification was done to evaluate the respective exons. Preliminary mutations were detected using restriction enzymes (BfaI and HhaI), which were then followed by sequencing of representative samples. The diabetic history, clinical and biochemical data were obtained after proper consent.ResultsOur data revealed no association of HNF4α (exon7) and GCK (exon8) gene mutation with MODY disease susceptibility in the Kashmiri population. On diagnosis, no MODY patient was given immediate insulin; instead, metformin (68%) or sulphonyl-urea (28%) and dietary changes (4%) were recommended. Later in life, 54% of MODY patients develop insulin dependency. The MODY probability was calculated to be 73.88% (±4.56). HbA1c levels were lower [7.48% (±1.64)] than in T1DM [9.17(±2.29%)].ConclusionsYoung early-onset diabetic patients were able to keep their HbA1c and blood glucose levels stable with a modified diet and metformin/sulphonyl-urea, but they may become insulin-dependent in the future, as seen in our study. As a result, prompt diagnosis and management are essential for avoiding complications. Furthermore, no HNF4α (exon7) or GCK (exon 8) mutations were found in MODY patients or T1DM/healthy non-diabetic controls.     

糖化血红蛋白与胰岛β细胞功能关系的研究

目的 探讨不同糖代谢状态糖化血红蛋白（HbA1c）与胰岛β细胞功能的关系.方法 选取2010年6月至2013年2月为评价糖耐量水平而来南京大学医学院鼓楼医院内分泌科就诊者913例,所有受试者均行75 g口服葡萄糖耐量试验（OGTT）及胰岛素释放试验,测定HbA1c,根据HbA1c水平将受试者分为HbA1c ＜5.7％（277例）、5.7％≤HbA1c≤6.4％（391例）及HbA1c＞6.4％组（245例）;根据OGTT结果分为正常糖耐量组（NGT,205例）,糖调节受损组（IGR,328例）及2型糖尿病组（T2DM,380例）.以1/稳态模型胰岛素抵抗指数（1/HOMA-IR）、Matsuda胰岛素敏感指数（ISIM）评价胰岛素敏感性,以处置指数DI（早时相DI30、总时相DI120）评估校正胰岛素敏感性之后的胰岛β细胞功能.多组计量资料间比较采用方差分析,分类计数资料采用卡方检验,胰岛功能相关指数在校正性别、年龄、BMI之后采用一般线性模型进行比较.结果 与HbA1c ＜5.7％组相比,5.7％≤HbA1c≤6.4％组的DI30、DI120、ISIM、1/HOMA-IR分别下降了39％、33％、13％、14％;HbA1c＞6.4％组的DI30、DI120、ISIM、1/HOMA-IR分别下降了68％、66％、21％、32％（F=12.765 ～ 317.316,均P＜0.05）.在正常糖耐量阶段的人群中,5.7％≤HbA1c≤6.4％组的DI30、DI120明显低于HbA1c＜5.7％组（F=4.516、4.215,P＜0.05）;在HbA1c＜ 5.7％的人群中,DI30及DI120按照NGT→ IGR→T2DM的方向下降（F =87.604、108.369,P＜0.05）.结论 胰岛β细胞功能的进行性衰退及胰岛素抵抗共同促进了HbA1 c的升高;HbA1c与血糖结合能够更好地反映个体胰岛功能情况.     

Triple genetic variation in the HNF-4alpha gene is associated with early-onset type 2 diabetes mellitus in a philippino family

Maturity-onset diabetes of the young-type 1 (MODY1) is a form of monogenic type 2 diabetes mellitus (T2DM) with long-term complications due to mutations in the HNF-4alpha gene. The HNF-4alpha gene is involved in hepatic differentiation and expression of genes regulating glucose transport, glycolysis, and lipid metabolism. The abnormal glucose-stimulated insulin secretion in MODY1 subjects may be due to reduced glucose transport and glycolysis. To date, 14 mutations in the HNF-4alpha gene have been identified as a cause of either MODY1 or late-onset type 2 diabetes. So far, no screening has been performed in subjects from the Philippines. We recruited a Philippino family with autosomal dominant early-onset type 2 diabetes and screened the proband for mutations in the genes for HNF-1alpha, GCK, HNF-4alpha, IPF-1, HNF-6, and NGN3. We identified a new missense mutation in exon 5 (V199I) of the HNF-4alpha gene and 2 new single-nucleotide substitutions in intron 4, IVS4-nt4 (G --> A) and IVS4-nt20 (C --> T), all cosegregating with diabetes in the 3 affected available siblings. These variations were not present in 100 normal healthy subjects. Bioinformatic analysis suggests that these variations in the whole, and overall the IVS4-nt4 variation located at splicing site, may affect the splicing potential of intron 4. We have biochemically and clinically characterized the Philippine-1 family. We suggest that the V199I missense mutation located in the ligand binding/dimerization domain of HNF-4alpha contributes to type 2 diabetes in the Philippine-1 family. The intron variations may contribute susceptibility to diabetes.     

不同糖耐量人群血清载脂蛋白A5的变化及其与糖脂代谢异常的相关性

目的 探讨不同糖耐量人群HbA1c与载脂蛋白A5 （ApoA5）及血脂的关系. 方法 将研究对象分为T2DM组98例、IGR组87例及糖耐量正常组（NGT） 100名.比较各组HbA1c、ApoA5、TC、TG、LDL-C和HDL-C水平. 结果 T2DM、IGR组HbA1 c,TC,TG,LDL-C高于NGT组,ApoA5、HDL-C低于NGT组（P＜0.05）;T2DM组HbA1 c,TC,TG,LDL-C高于IGR组,ApoA5、HDL-C低于IGR组（P＜0.05）.糖耐量异常程度与血浆ApoA5呈负相关,ApoA5与TC,TG,LDL-C,HbA1c,HOMA-IR,BMI和WHR呈负相关,与HDL-C及HOMA-β呈正相关. 结论 ApoA5可能是HbA1c与脂代谢异常的预测指标.     

血糖三项检验的数据挖掘及应用

目的：对糖尿病（DM）患者血糖三项[餐前血糖、餐后2 h血糖、糖化血红蛋白（HbA1c）]和临床信息进行数据挖掘,评估血糖三项诊断DM的价值。方法回顾性分析泸州地区7614例中老年人血糖三项检测结果及诊断信息,参考美国临床实验室标准化委员会C28-A2文件推荐方法估计55～62岁人群中血糖三项的参考区间,构建诊断和筛查DM的受试者工作曲线（ ROC）数据集,用验后概率来扩展Roc数据集。结果55～62岁人群血糖三项的参考区间分别为：餐前血糖3．89～6．64 mmol/L,餐后2 h血糖4．11～7．73 mmol/L,HbA1c ＜6．2％;血糖三项对DM的诊断价值为餐后2 h血糖＞餐前血糖＞HbA1c ,其ROC下面积分别为0．975、0．887、0．849。诊断DM的切点：餐前血糖6．8 mmol/L;餐后2 h血糖11．0 mmol/L,HbA1c ＜6．2％。经临床实践验证,餐前血糖诊断DM符合率为83．02％,餐后2 h血糖为95．57％。结论血糖三项检验数据挖掘明显提高了DM的诊断价值。     

High prevalence of a missense mutation of the glucokinase gene in gestational diabetic patients due to a founder-effect in a local population

Summary A high proportion of the female patients who are members of maturity onset diabetes of the young (MODY) pedigrees, and whose diabetes mellitus is due to a glucokinase mutation, originally presented with gestational diabetes. To establish whether glucokinase mutations could be a common cause of gestational diabetes, we studied 50 subjects who presented with gestational diabetes and on follow-up had hyperglycaemia (5.5–10.0 mmol/l). Screening for glucokinase mutations using single-stranded conformational polymorphism (SSCP) analysis detected a missense mutation at position 299 (Gly²⁹⁹→ Arg) in three subjects. As two pedigrees in the Oxford area had the same glucokinase mutation, we suspected the role of a founder-effect, and carried out pedigree extension, haplotype construction (using microsatellite markers GCK1 and GCK2) and mutation screening of at-risk subjects from the same geographical area. One of the gestational diabetic subjects was found to be related to one of the previous pedigrees via her paternal grandmother. Subjects with the mutation were found to have the Z + 4/2 (GCK1/GCK2) haplotype, suggesting that the observed high prevalence of the Gly²⁹⁹→ Arg glucokinase mutation in the Oxford region was due to a founder-effect. Since glucokinase mutations predominantly induce subclinical hyperglycaemia, it is likely that in the locality of other pedigrees there will be undiagnosed subjects with the same glucokinase mutation, which remains undetected unless pregnancy occurs. [Diabetologia (1996) 39: 1325–1328] Received: 13 February 1996 and in revised form: 7 May 1996     

Haploinsufficiency at GCK gene is not a frequent event in MODY2 patients

Objective  The aim of this study was to characterize glucokinase ( GCK ) alterations in maturity-onset diabetes of the young 2 (MODY2)-suspected patients and to investigate their clinical characteristics in relation to the parental origin of the mutation.
Patients and methods  We studied a group of 57 unrelated Spanish patients presenting with MODY2 phenotype. Patients without mutation in the coding region of the GCK gene were screened for rearrangements by Multiplex Ligation-dependent Probe Amplification (MLPA). After classification according to the parental origin of the mutation, clinical characteristics were compared between the groups.
Results  We detected a point mutation or small deletion or insertion of the GCK gene in 47 patients (82·5%); 19 mutations were novel. In addition, we found a whole-gene deletion by MLPA. Patients carrying a GCK gene defect and those with MODY of unknown genetic origin shows similar phenotypes.
Comparison of clinical parameters according to the origin of the mutation did not show any differences in the birth weight (BW) nor in age at diagnosis. Patients who inherited the mutation from the father had higher fasting glucose levels at diagnosis.
Conclusion  Although the presence of haploinsufficiency of GCK is not a common cause of MODY2, gene dose analysis should be performed when no mutation is found.
Strict maternal euglycaemia can contribute to intrauterine growth restriction and low BW when the foetus has inherited the GCK mutation from the mother. As foetal genotype in generally is not known, serial foetal abdominal scans may act as a surrogate for this.